Government incentives and penalties are increasing the rate of adoption of Electronic Medical Records (EMR) in hospital settings. EMR documentation systems are expected to increase quality, safety, effectiveness, and efficiency of health care delivery through improvements in legibility and organization of patient information, communication among providers, and creation of a centralized repository of patient information that can be built and accessed by multiple providers and clinics. However, these benefits remain largely unrealized. At present, there is a lack of research on impacts of EMR on provider workflow, and unintended consequences such as disruption of cognitive flow and increased difficulty communicating with other providers are observed in the literature. Additionally, the implementation process can present problems that prevent the EMR from reaching maximum operability;when EMR systems are added and other documentation technologies not removed from a work system, the EMR may actually exacerbate the inefficiencies and errors it was designed to correct. This dissertation study examines the impact of EMR implementation on the work processes and information flow in an inpatient labor &delivery unit. Findings will result in a set of guidelines and considerations for effective EMR implementation processes that help hospitals and providers to re-engineer current work systems and documentation routines around the new system. I conduct an ethnographic study utilizing in-depth interactive observations and semi- structured interviews in the labor &delivery unit of an academic medical center over the course of 16 months. The study period includes several months preceding EMR implementation, the time surrounding the "go live" phase, and the eight months after. The unit utilizes a hybrid work system where providers use multiple high- and low-tech documentation systems. In particular, a stand-alone fetal monitoring flow sheet program is used for documentation with no plans to phase this program out;this is a situation common in labor &delivery units across the country. I use workflow and narrative network analyses to analyze data and map work processes and information flow in labor &delivery pre-and post-implementation. Content analysis guided by Grounded theory, which outlines a set of methodologically rigorous steps for coding qualitative data, is used to analyze interview data assessing the impact of EMR implementation in an environment where multiple other documentation systems are in place on provider practice. PUBLIC HEALTH RELEVANCE: This dissertation addresses a pressing gap in the literature about the impact of Electronic Medical Record (EMR) implementation on work processes in a hospital work system where multiple health information technologies are already in place. Additionally, this study maps workflow and EMR use in labor &delivery, an under-studied area in health informatics. Theoretically, this project examines how usage of documentation information technologies contributes to centralization or fragmentation of information, consistency of documentation routines, and quality of communication and coordination between providers, resulting in a set of guidelines for hospitals on how to successfully re-engineer work systems to optimize EMR functionality and maximize EMR benefits related to efficiency and safety.